Suprapatellar insertion system, kit and method

ABSTRACT

A system is provided for inserting and securing, through a suprapatellar region of a leg, a nail into a medullary canal of a bone. The system can include a flexible sleeve configured to be partially inserted in the leg. The flexible sleeve can define a leading end and a trailing end spaced apart from the leading end along a first axis. The flexible sleeve can define a first cannulation that extends along the first axis between the leading and trailing ends. The first cannulation can be sized to receive therethrough at least the intramedullary nail. The system can further include a retaining member configured support at least a portion of the flexible sleeve. The retaining member can be configured to position the flexible sleeve through the suprapatellar region of the leg such that the flexible sleeve leading end is aligned with the proximal end of the bone. The intramedullary nail can be insertable through the flexible sleeve and into the medullary canal.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a divisional of U.S. application Ser. No.14/823,606, filed Aug. 11, 2015 which is a divisional of U.S.application Ser. No. 13/729,572, filed Dec. 28, 2012, Now U.S. Pat. No.9,101,432 which claims priority to U.S. Application Ser. No. 61/581,529,filed Dec. 29, 2011, the disclosures of which are hereby incorporated byreference as if set forth in their entirety herein.

FIELD OF THE INVENTION

The present disclosure relates to a system, kit and method for theinsertion and fixation of a nail into a medullary canal of a bone.

BACKGROUND OF THE INVENTION

A nail may be inserted into a medullary canal of the bone to securetogether bone fragments of a tibia separated by a fracture. Theintramedullary nail is inserted into the canal such that nail spans thefracture. Anchors can be inserted through the bone and into theintramedullary nail at opposing sides of the fracture, thereby fixingthe intramedullary nail to the bone. The intramedullary nail can remainin the medullary canal at least until the fracture is fused. In oneexemplary method, a intramedullary nail is inserted into the medullarycanal of the tibia while the patient's knee is bent at a 90 degreeangle. When the knee is bent to 90 degrees during nail insertion, thequadriceps muscle pulls the proximal bone fragment askew relative to thedistal bone fragment and bone fragment misalignment can occur. Insertingthe intramedullary nail while the patient's knee is bent at a 10-20degree angle can reduce the risk of bone fragment misalignment becausethe quadriceps muscle does not pull the proximal bone fragment of thebone to such an extent compared to when the knee is bent at a 90 degreeangle or more.

There is a need for an improved system, kit and method for inserting anail into a bone, and the subsequent fixation of the intramedullary nailto the bone.

BRIEF SUMMARY OF THE INVENTION

In accordance with an embodiment of the present disclosure, a system isprovided for inserting and securing, through a suprapatellar region of aleg, a nail into a medullary canal of a bone. The system can include aflexible sleeve configured to be partially inserted in the leg. Theflexible sleeve can define a leading end and a trailing end spaced apartfrom the leading end along a first axis. The flexible sleeve can definea first cannulation that extends along the first axis between theleading and trailing ends. The first cannulation can be sized to receivetherethrough at least the intramedullary nail. The system can furtherinclude a retaining member configured support at least a portion of theflexible sleeve. The retaining member can be configured to position theflexible sleeve through the suprapatellar region of the leg such thatthe flexible sleeve leading end is aligned with the proximal end of thebone. The intramedullary nail can be insertable through the flexiblesleeve and into the medullary canal.

BRIEF DESCRIPTION OF THE DRAWINGS

The foregoing summary, as well as the following detailed description ofa preferred embodiment, are better understood when read in conjunctionwith the appended diagrammatic drawings. For the purpose of illustratingthe present disclosure, reference to the drawings is made. The scope ofthe disclosure is not limited, however, to the specificinstrumentalities disclosed in the drawings. In the drawings:

FIG. 1 is a perspective view of a system used to insert anintramedullary nail into a medullary canal of a bone through asuprapatellar region of a leg, in accordance with an embodiment of thepresent disclosure;

FIG. 2A is a perspective view of a retaining device used with the systemshown in FIG. 1;

FIG. 2B is a plan view of the retaining device shown in FIG. 2A;

FIG. 2C is a side view the retaining device shown FIG. 2A;

FIGS. 3A and 3B are perspective and sectional views, respectively, of aflexible sleeve used with the system shown in FIG. 1;

FIGS. 4A and 4B are perspective and sectional views, respectively, of arigid sleeve used with the system shown in FIG. 1;

FIG. 5 is a perspective view of a trocar used with the system shown inFIG. 1;

FIG. 6A is a perspective view of a wire guide used with the system shownin FIG. 1;

FIG. 6B is an end view of the wire guide shown in FIG. 6A;

FIGS. 7A and 7B illustrate a retaining device holding a flexible sleevewith the rigid sleeve inserted in the flexible sleeve, in accordancewith an embodiment of the present disclosure;

FIG. 8A is a perspective view of an insertion device of the system shownin FIG. 1;

FIG. 8B is a sectional view of an insertion device of the system shownin FIG. 8A taken along lines 8B-8B.

FIG. 9A is a perspective view of the insertion device shown in FIG. 2Aillustrating a connection device, a drive mechanism, and a portion of anintramedullary nail;

FIG. 9B is an enlarged partial perspective view of the insertion deviceand a proximal end of the intramedullary nail shown in FIG. 10A;

FIG. 9C is a perspective view an intramedullary nail shown in FIG. 9B;

FIG. 10 is a perspective view of an aiming device of the system shown inFIG. 1;

FIGS. 11A and 11B are side and sectional views, respectively of a guidesleeve used in the system shown in FIG. 1;

FIGS. 12A and 12B illustrate the right leg of a patient prepared forreceiving an intramedullary nail into the medullary canal of the bone inaccordance with an embodiment of the present disclosure;

FIG. 13 illustrates an exemplary distractor used to reduce a fracture ina tibia in accordance with an embodiment of the present disclosure;

FIG. 14 illustrates the retaining device supporting the flexible sleeve,a rigid sleeve partially within the flexible sleeve, and a trocarpartially within the rigid sleeve, and positioned in the leg such thatthe trocar tip engages the proximal end of the tibia, in accordance withan embodiment of the present disclosure;

FIG. 15 illustrates the retaining device supporting the flexible sleeve,the rigid sleeve, and a wire guide inserted in the rigid and flexiblesleeves, with a wire positioned in the wire guide, in accordance with anembodiment of the present disclosure;

FIG. 16 illustrates the retaining device supporting the flexible sleeveand the rigid sleeve, with an additional wire coupling the retainingdevice to the femur of a the leg, with the rigid sleeve positioned toreceive additional instrumentation therein, in accordance with anembodiment of the present disclosure; and

FIG. 17 is a perspective view illustrating how the insertion device isused to insert an intramedullary nail through the flexible sleeve andinto a medullary canal of a tibia in accordance with an embodiment ofthe present disclosure.

DETAILED DESCRIPTION OF PREFERRED EMBODIMENTS

Referring generally to FIGS. 1 and 7A, the system 1 is configured toprepare a medullary canal C of a bone T in a leg, insert anintramedullary nail 300 (sometimes referred to herein as a “nail”) intothe medullary canal C when the knee is flexed to between 10 and 20degrees flexion as shown in FIGS. 1 and 12, and subsequently fix theintramedullary nail 300 to the bone T. The bone T can define a proximalend and a distal end spaced apart from the proximal end along an axisTB1. A superior-inferior direction S1 or first direction extends alongthe axis TB1. The femur F can have a femur axis F1 and the degree offlexion is defined by the angle formed by the femur axis F1 and the boneaxis TB1. The system 1 can include a retaining device 50 (FIGS. 2A-2C)and at least one flexible protective sleeve 40 (FIGS. 7A and 7B)supported by the retaining device 50 such that the at least one flexibleprotective sleeve can be inserted through a suprapatellar region SR(FIG. 12B) of the leg. The suprapatellar region SR as used herein meansthe region on the leg that is generally cranial to the patella P.Further, a rigid sleeve 30 can be at least partially disposed in theflexible protective sleeve 40. The rigid sleeve 30 is configured toreceive therein canal preparation instrumentation for instance, aportion of a trocar 80, a drilling assembly and a reamer. A wire guide90 (FIG. 6A) can also be disposed at least partially within the rigidsleeve 30 and is used to guide one or more wires 106 toward the bone T(FIG. 15). The wire 106 can guide canal preparation instrumentationtoward the bone T, as further detailed below. The flexible sleeve 40 canflex as needed to accommodate a curved portions of the nail 300.Further, the flexible sleeve 40 is configured to protect tissue duringthe canal C preparation and nail 300 insertion phases, while the rigidsleeve 30 can protect the flexible sleeve 40 from the instrumentationdisposed in the rigid sleeve 30.

Referring to FIG. 1, the system 1 can also include an insertion device10 connectable to the intramedullary nail 300 and further configured toadvance the intramedullary nail 300 along the superior-inferiordirection S1 through the at least one flexible protective sleeve 40 andinto the medullary canal C, for instance when the rigid sleeve 30 hasbeen removed from the flexible sleeve 40. The system 1 also includes anaiming device 200 configured to guide one or more anchors 8 into thebone T and nail 300 along a transverse direction S2 or second directionthat is generally transverse to the superior-inferior direction S1. Itshould be appreciated that the transverse direction S2 can be anyradially aligned direction that is transverse to the superior-inferiordirection S1. The aiming device 200 is configured to support a guidesleeve 60 such that guide sleeve 60 is positioned along the transversedirection S2 toward the bone T. The anchor 8 can be inserted through theguide sleeve 60 and fixed to the bone T, as shown in FIG. 1, and furtherdetailed below. As should be appreciated, the guide sleeve 60 protectstissue during the intramedullary nail 300 fixation phases as furtherdescribed below.

The system 1 as described herein may be used to insert nail through thesuprapatellar region SR when the patient's knee is positioned betweenabout 10 to 20 degree flexion. The knee flexed to between 10 and 20degrees during nail 300 insertion can minimize possible bone fragmentmisalignment compared to the procedure where the knee is positioned at90 degree flexion and the quadriceps muscles pulls the proximal bonefragment askew. The system 1, kit and method as described herein may beused to stabilize fractures in proximal tibia, distal tibia, and thetibial shaft, open and closed tibial shaft fractures, tibial malunionsand nonunions, and certain pre- and postisthmic fractures, for example.

The system 1 may also include preparation instrumentation used tofacilitate preparation of the medullary canal C for suprapatellarinsertion of a nail 300 therein. For instance, preparationinstrumentation may include a drill assembly (not shown) with acannualated drill bit positioned distally on the drill assembly, whereinthe cannualated drill bit is slidable along a guide wire 106 to preparethe canal C. A reamer (not shown) can be used as needed to furtherprepare the medullary canal C for receiving the intramedullary nail 300therein, wherein reamer is cannualated so as to slidable along the wire160 through the rigid sleeve 30 toward the bone canal C.

The system 1 may also include fixation and insertion instrumentationused to facilitate inserting the intramedullary nail 300 into the canalC. For instance, a cap and hammer assembly (not shown) can be used toadvance the intramedullary nail 300 into the canal C. When theintramedullary nail 300 is in position, a bone drill assembly (notshown) can be disposed in the guide sleeve 60 to prepare the bone T forreceiving the anchor 8. When the bone drill assembly is removed, thedrive mechanism 70 and anchor 8 can be inserted into the guide sleeve60.

With reference to FIGS. 2A-2C, 7A and 7B, the retaining device 50 isconfigured to retain one or more sleeves 30, 40 therein. Further, theretaining device 50 is configured to position the respective sleeves atleast partially in the leg such that the instrumentation, for instance,the trocar 80, insertion device 10 and nail 300, can be disposed throughthe sleeves 30 and 40 as needed. As shown in FIG. 2A, the retainingdevice 50 can include a retaining member 540 supported for instance, bya handle 520. The retaining member 540 is spaced apart from the handle520 along a retaining device axis R3 or first retaining member axis R3.The handle 520 is configured to ergonomically receive a user's hand. Forinstance the handle 520 is shown elongate along the axis R3, but itshould be appreciated the handle 520 can have any configuration, shape,geometry, or include any additional device or structure that can be heldby a user.

Continuing with FIGS. 2A-2C, 7A and 7B, the retaining member 540 isconfigured to hold at least the flexible sleeve 40. As discussed above,the rigid sleeve 30 can be inserted in the flexible sleeve cannulation45 (FIGS. 7A and 7B). The retaining member 540 is also configured to fixthe retaining device 50 in position on the patient's leg. The retainingmember 540 defines a retaining body 542 connected to or for instanceintegral with an intermediate body 510. The intermediate body 510 candefine one or more bores 512 and 514 extending transversely along axisR3 through the intermediate body 510. The one or more bores 512, 514 areconfigured to receive a fixation wire 107 (FIG. 17) therethrough thatcan fix the retaining device 50 in position relative to the leg. Asshown in FIG. 17, the fixation wire 107 can define a distal end 107 d.The distal end 107 d can be inserted through either of the bores 512 or514 to engage the femur F such that retaining device 50 is fixed in thedesired position relative to the leg.

The retaining body 542 can also define an opening 560 sized to receiveat least a portion of the flexible sleeve 40, and/or at least a portionof the rigid sleeve 30. The retaining body 542 defines a first surface544, and a second surface 546 spaced apart from the first surface 544along a retaining device transverse axis R1. The body 542 furtherdefines a wall 548 at least partially connecting and extending betweenthe first and second surfaces 544 and 546 along the retaining devicetransverse axis R1 The retaining body 542 can also define acircumferential channel 580 disposed in the opening 560 that isconfigured to receive a portion of the flexible sleeve 40.

The retaining member 540 can include at least one locking member 570 a,570 b (two are shown) configured to selectively lock and unlock theflexible sleeve 40 and rigid sleeve 30 in the retaining device 50. Thewall 548 can define at least one inner cavity (not shown) for supportingthe locking member 571. The locking member 570 is shown positioned inthe wall 548 of the retaining body 542. The locking member 570 defines alocking member body 571 and a projection 574 a, b operably connected tothe body 571 a, b and extending through the wall cavity along a lateralretaining device axis R2, which is perpendicular to the axes R1 and R2.In an embodiment, the body 571 a is configured to bias the projection574 a at least partially in to the opening 560. When the locking member570 a is depressed along the axis R2, the projection 574 a is retractedwithin the wall 548, and the flexible sleeve 40 can be inserted into orpulled from the channel 580. When the locking member is 570 is released,the projection 574 is biased into the opening 580 such that theprojection 574 can help prevent axial displacement of the flexiblesleeve 40 along the axis R1.

The retaining member 540 can include a moveable blocking device 590configured to selectively obstruct the opening 560, with can preventpossible axial displacement along the axis R1 of the rigid sleeve 30,flexible sleeve 40, and/or trocar 80. The blocking device 590 can definea base 594 supported for instance by the retaining body 542. Theblocking device 590 can further include a blocking member 592 rotatablycoupled to base 594 so that the blocking member 592 can move between afirst position X shown in FIGS. 2A and 2B wherein the opening 560 isunobstructed by the blocking member 592, and a second position Y (shownin dashed lines in FIG. 2C) wherein the blocking member 592 at leastpartially obstructs the opening 560. The blocking member 592 can furtherdefine a surface 592 b that faces the retaining body 542. The blockingmember 592 is positioned on the base 594 so that the surface 592 b isspaced apart from the retaining body 542 along the axis R1 a distanceBD. The distance BD is defined as the distance between the surface 592 bof the blocking member 592 and the surface 544 of the retaining body542. The blocking member 592 is spaced apart from the surface 544 of theretaining body 542 such that when blocking member 592 is rotated in thedirection Q (FIG. 2A), at least a portion of the blocking member 592 isin at least partial axial alignment along the axis R1 with the opening560.

While a rotating blocking device 590 is shown in the figures anddescribed above, the blocking device is not limited to such aconfiguration. In alternative embodiments for example, the blockingdevice 590 may be configured as a slidable member disposed on the base594 and spaced apart from the retaining body surface 544. In such anembodiment the slidable member (not shown) is moveable from a firstposition wherein access to the opening 560 is unobstructed to a secondposition wherein the opening 560 is at least partially blocked by theslidable member. It should be appreciated that other blocking devices,mechanisms, and structures may be used well.

With reference to FIGS. 3A and 3B, the flexible sleeve 40 is configuredto flex as need to accommodate insertion of the nail 300 therethrough.Further, the flexible sleeve 40 is configured to protect soft tissuewhile the tibial nail 300 is inserted into the medullary canal C of thebone T. Further, the flexible sleeve 40 is also configured to protectsoft tissue while the medullary canal C is being prepared insertion ofthe intramedullary nail 300 therein, for instance when a drill bit isdisposed in the flexible sleeve 40. The flexible sleeve 40 defines atrailing end 42, and a leading end 44 spaced apart from the trailing end42 along a longitudinal axis P1, and body portion 41 extending betweenthe leading and trailing ends 44, 42. The flexible sleeve 40 defines alongitudinal cannulation 45 extending along the longitudinal axis P1between the trailing and leading ends 42, 44. The flexible sleevedefines an inner surface 49, which defines the cannulation 45. Thetrailing end 42 includes an outer rim 46 having first and second radialdetents 47 and 48 disposed around the outer rim 46 in a diametricallyopposed relation. The retaining member channel 580 also definesdiametrically opposed protrusions 586 and 588 (FIG. 2C). The first andsecond radial detents 47 and 48 can receive the opposed protrusions 586and 588 (FIG. 2C). In the illustrated embodiment, the cross-sectionaldimension of the outer rim 46 is larger than the cross-sectionaldimensional of any other portion of the body portion 41. The flexiblesleeve 40 has a length such that when it is positioned within the kneeK, the leading end 42 can extend to but not enter or penetrate theproximal end of bone.

The flexible sleeve cannulation 45 is sized to receive at least theintramedullary nail 300 and insertion member 11 therein. Specifically,the cannulation 45 defines a cross-sectional dimension 410 extendingtransverse to the axis P1 between opposing portions of the inner surface49. When the intramedullary nail 300 is inserted through thelongitudinal cannulation 45, the flexible sleeve 40 can bend or flex toaccommodate any curved portion 12 of the intramedullary nail 300. Theflexible sleeve 40 is configured to flex so as to change a shape of thefirst axis P1 from a first configuration to a second configuration,wherein the second configuration is different than the firstconfiguration. The first configuration can be the configuration of thefirst axis P1 and flexible sleeve as shown in FIGS. 3A and 3B. Thesecond configuration can be defined as when the axis P1 is curved,crimped, bent or twisted for instance, when the curved nail 300 isinserted in the sleeve cannulation 45 of the flexible sleeve 40.

The flexible sleeve 40 is formed of a soft, pliable, and flexiblematerial so that the sleeve 40 can flex, bend, and/or contort when fromthe first configuration to the second configuration. Stated differently,the flexible sleeve 40 is designed to withstand, by flexing as needed,the rigors of medullary canal C preparation and also the insertion ofthe nail 300 therein. In an embodiment, the flexible sleeve 40 is madeof a thermoplastic elastomer. An exemplary elastomer is an elastomersold under the trademark Santoprene™ by Exxon Mobil Corporation. Whilean elastomer is preferred, other materials may be used as well. Forexample, the flexible sleeve 40 may be formed any polymeric material,including one or more polymers, and/or copolymer, polymer blend, or acomposition of a polymers, co-polymers, additives and/or fillers thatyield a soft, flexible and pliable material yet retain the structuralintegrity in use.

Referring to FIGS. 4A and 4B, a rigid sleeve 30 is shown that isconfigured to be at least partially inserted inside the flexible sleeve40. The rigid sleeve 30 defines a leading end 31 a trailing end 33spaced apart from the leading end 31 along an axis P2, and a shaft 34extending between the leading and trailing ends 31, 33. The rigid sleeve30 defines a longitudinal cannulation 35 extending along the axis P2through the shaft 34 and between the leading and trailing ends 31, 33.The longitudinal cannulation 35 is sized to receive at least a portionof a trocar 80 and/or the wire guide 90, as described above. Further,the cannulation 35 is sized to receive at least a portion of the drillbit (not shown) and reamer (not shown). The rigid sleeve 30 is elongatewith a length selected for suprapatellar insertion. The shaft 34 definesand outer surface 131 and opposed inner surface 133. Further, the shaft34 defines a rigid sleeve cross-sectional dimension 130 extendingtransverse to the axis P1 between opposing portions of the shaft outersurface 131. The rigid sleeve cross-sectional dimension 130 is less thanor about equal to the flexible sleeve cannulation cross-sectionaldimension 410, such that the shaft 34 can be inserted in the flexiblesleeve cannulation 45. Further, the cannulation 35 defines rigid sleevecannulation cross-sectional dimension 132 extending transverse to theaxis P1 between opposing portions of the inner surface 133. The rigidsleeve 30 has a length so as to extend from at least an incision site104 (FIG. 12B) to the proximal surface TP of the proximal tibia. Therigid sleeve 30 may be formed of steel, stainless steel, a stainlesssteel and/or metallic alloy, or any other durable, rigid, andbiocompatible material. The rigid sleeve 30 protects the flexible sleeve40 during the drilling and reaming operations discussed below.

The rigid sleeve 30 further defines an engagement member 36 disposed atthe trailing end 33 of the sleeve 30 and configured to engage theretaining device 50. The engagement member 36 can define an engagementbody 38 with a ridge 39 projecting radially outwardly from the shaft 34in a direction that is transverse to the axis P2, and at least onefinger 32 (a finger pair 32 is shown) extending radially outward fromthe engagement body 38. As illustrated, a cross-sectional dimension ofthe engagement member 36 that extends along a direction transverse tothe rigid sleeve axis P2 is larger than the cross-sectional dimension ofthe shaft 34 and the distal end 31 of the rigid protective sleeve 30such that when the rigid sleeve 30 is inserted into the flexible sleeve40, the ridge 39 abuts a portion of the flexible sleeve 40 preventingfurther advancement of the rigid sleeve 30 through the flexible sleevecannulation 45. The at least one finger 32 permits a user to remove therigid sleeve 30 from the sleeve 40 by grasping finger 32 and pulling therigid sleeve 30 out of the flexible sleeve 40. Further, the engagementbody 38 can define at least one recess 37 a, 37 b that is configured toengage a portion of the retaining device 50. Specifically, the recess 37a and 37 b are configured to receive corresponding projections 574 a,574 b of the locking members 570 a and 570 b (FIGS. 2A-2C). When thelocking members 570 a and 570 b are depressed by the user along axis R2,the projections 574 a, 574 b are retracted within the wall 548, and therigid sleeve 30 can be inserted into the flexible sleeve cannulation 45until the engagement member 36 is partially disposed within theretaining member opening 560, as shown in FIG. 8A. When the lockingmembers 570 a and 570 b are released, the respective projections 574 aand 574 b are biased through the wall 548 into the opening 580 along theaxis R2 and into engagement with engagement member recesses 37 a and 37b respectively, further the locking the rigid sleeve 30 in position.

Turning to FIG. 5, the trocar 80 is configured to be at least partiallydisposed in the rigid sleeve 30. When trocar 80 is inserted in the rigidsleeve 30, the trocar 80, sleeves 30 and 40 can be supported by theretaining device 50 for positioning in the leg. The trocar 80 can beused to displace soft tissue in the suprapatellar region SR. The trocar80 defines a trailing end 81, a leading end 83 spaced apart from thetrailing end 81 along a trocar axis T1, and a shaft 86 disposed betweenthe trailing and leading ends 81 and 83, respectively. The trocar 80further defines a trocar engagement member 84 at the trocar trailing end81 and a tapered tip 82 at the trocar leading end 83. The tip 82 andshaft 86 are sized for slidable engagement within the cannulation 35 ofthe rigid sleeve 30 such that the tip 82 protrudes from the leading ends44 and 31 of the respective sleeve 40 and 30. The shaft 86 defines anouter surface 181. The shaft 86 further defines a rigid sleevecross-sectional dimension 186 extending transverse to the axis T1 andbetween opposing portions of the outer surface 181. The trocar shaftcross-sectional dimension 186 is less than or about equal to the rigidsleeve cannulation cross-sectional dimension 332, such the shaft 86 cabbe inserted in the rigid sleeve cannulation 35. Accordingly, the trocar80 is configured for insertion in the cannulation 35 of the rigid sleeve30 such that the tip 82 protrudes from the leading end 31 of the rigidsleeve 30 and the leading end 44 of the flexible sleeve 40. While theillustrated system 1 shows the trocar 80 inserted directly within therigid sleeve 30, in other embodiments, the trocar 80 may be at leastpartially inserted directly within the cannulation 45 of the flexiblesleeve 40.

The engagement member 84 of the trocar 80 is configured to engage atleast a portion of the rigid sleeve 30 and/or the retaining device 50.The engagement member 84 may include a body 85 that forms a ridge 88projecting radially outwardly from the shaft 86 in a direction that istransverse to the axis T1. When the trocar 80 inserted into the rigidsleeve 30, the ridge 88 abuts the engagement member 36 of the rigidsleeve 30, thereby preventing further advancement of the trocar 80 alongthe sleeve cannulation 35. Accordingly, the cross-sectional dimension ofthe enlarged member 84 is larger than the cross-sectional dimension ofthe shaft 86 and the tip 82. The body 85 further defines a channel 87circumferentially disposed around the body 85, and is configured tofacilitate manual manipulation by the surgeon. It should be appreciatedthat the body 85 can also define multiple grooves, flutes, holes, divotsor knurls as needed.

The trocar tip 82 is configured to displace soft tissue in the areaaround and between the proximal bone TP and patella P. It should beappreciated that the tip 82 may have any shape, geometry, or include anadditional structure or device that could displace soft tissue withinthe knee. For instance, the tip 82 can define a curved end, such as ahemispherical cap similar to that shown in FIG. 7. In other embodiments,the trocar tip 82 may have a wedge shape. Further, the degree of taperalong the tip 82 may be varied as needed.

The trocar 80 may be formed of any biocompatible material, such as apolymeric material, metallic and/or alloy materials as needed. In apreferred embodiment, the trocar 80 may be formed of polyether etherketone (PEEK). However, the system 1 is not limited to a PEEK trocar.

Referring to FIGS. 6A and 6B, the wire guide 90 is configured to be atleast partially disposed in the rigid sleeve 30. The wire guide 90 isalso further configured to guide one or more wires 106 a, 106 b (FIG.15) toward a desired anatomical site when the wire guide 90 is disposedwith the sleeves 30, 40 and the sleeves 30, 40 are supported by theretaining device 50 partially within the leg. The wire guide 90 isconfigured to guide a first wire 106 a toward a first anatomicallocation, for instance the location on the proximal end of the bone Twhere the canal C is to be formed. If needed, a second wire 106 b can beguided toward a more desirable second anatomical location while the wireguide 90 is disposed in the rigid sleeve 30 and the first wire 106 aremains in the wire guide 90.

Continuing with FIGS. 6A and 6B, the wire guide 90 defines a proximalend 95, and a distal end 93 spaced apart from the proximal end 95 alonga wire guide axis W1. The wire guide 90 can also define an elongateshaft 94 extending between the opposed proximal and distal ends 93 and95 along the wire guide axis W1. The proximal end 95 of the wire guide90 defines an enlarged member 96 configured to engage a portion of therigid sleeve 30 when the wire guide 90 is disposed partially within therigid sleeve 30. The distal end 93 of the wire guide 90 can define a tip91. The shaft 94 and tip 91 are sized to be slidably received in therigid sleeve cannulation 35, while the enlarged member body 98 engagesthe trailing end 33 of the rigid sleeve 30, preventing furtheradvancement of the wire guide 90 through the rigid sleeve cannulation35. The wire guide shaft 94 defines and outer surface 191. The shaft 94further defines a cross-sectional dimension 194 that extends betweenopposing portion s of the shaft outer surface 191 and along a wiretransverse direction WT that is transverse with respect to the axis W1.The wire guide cross-sectional dimension 194 is less than or about equalto the rigid sleeve cannulation cross-sectional dimension 132. The wireguide is thus configured to be slidable received in the rigid sleevecannulation 45.

The enlarged member 96 defines a body 98 including a ridge 98 aprojecting radially outwardly from the shaft 94 in along the wiretransverse direction WT. When the wire guide 90 is inserted into rigidsleeve 30, the ridge 98 a can abut the engagement member 36 of the rigidsleeve 30. The enlarged member body 98 can define grip portions 94 thatfacilitate manipulation by the surgeon, for instance to rotate the wireguide 90 within the rigid sleeve 30 so as to reposition the wires 106 asneeded.

The enlarged member body 98 can also define first and second bores 91and 92, each of which are configured to receive the wires 106 a or 106 b(FIG. 15) therein. Each bore 91 and 92 can define a cross-sectionaldimension extending along a wire transverse direction WT. The wires 106a, 106 b can define a wire cross-sectional dimension. Thecross-sectional dimensions of the bores 91 and 92 are larger than thecross-sectional dimensions of the wires 106 a and 106 b. The first bore91 is disposed along the radial center C of the wire guide 90 andextends along the wire guide axis W1 toward the distal end 93. The tip91 can define a first bore exit portion 92 e. The second bore 92 islaterally offset a distance LD relative to the first bore 91. The wireguide shaft 94 can define a groove 92 g (FIG. 6A) that extends along theshaft 94 toward the tip 91, and a bridge portion 97 that spans thegroove 92 g along the transverse direction WT. The second bore 92extends through the enlarged member body 98 and is in open communicationwith the groove 92 g at the body ridge 98 a. The tip 91 can define agroove end 92 e.

Referring to FIGS. 9B and 9C, a nail 300 can include a proximal end 302and a distal end 304 spaced apart from the proximal end 302 along alongitudinal direction L. The longitudinal direction L of theintramedullary nail 300 refers to the length direction theintramedullary nail 300. The intramedullary nail 300 defines a nail bore306 extending at least partially between the proximal and distal nailends along the longitudinal direction L. The intramedullary nail 300also defines a plurality of openings 305 disposed at the distal andproximal ends of the intramedullary nail 300, respectively, and areconfigured receive one or more anchors 8. The intramedullary nailopenings 305 a, 305 b, 305 c, and 305 d are positioned at differentlocations and orientations on the proximal end 302 of the intramedullarynail 300 so as to receive therein anchors 8. The distal end 304 can havesimilar openings 305. The intramedullary nail 300 may be elongate alongthe longitudinal direction L and can further define at least one curvedportion 312 disposed between the proximal end 302 and the distal end304. The curved portion 312 aligns the intramedullary nail 300 with theproximal tibia relative to the tibial shaft and/or the distal tibia andtibial shaft. The nail 300 also defines a cross-sectional dimension 350that extend transversely to the longitudinal direction L of the nail300. The nail 300 can define a nail outer surface 351. The nail 300 canfurther define at least one cross-sectional dimension 350 extendingbetween opposed portions the nail outer surface 351. The nailcross-sectional dimension 350 is less than or about equal to theflexible sleeve cannulation cross-sectional dimension 410. The nail 300is thus configured to be slidable received in the flexible sleevecannulation 45. It should be appreciated that the nail can have varyingcross-section dimensions as illustrated in FIG. 9C. In alternateembodiments, the intramedullary nail 300 can be generally linear asneeded for the particular fracture on or position within the bone T. Itshould be appreciated that any nail 300 may be used as described herein.Different sized nails 300 may be used, according the fracturelocation(s) and/or anatomical constraints. For example, theintramedullary nail 300 can have one more selected diameters, lengths,and or profiles, as needed.

Referring to FIGS. 8A through 9B, the insertion device 10 can include aninsertion device body 110, an insertion member 11 extending from theinsertion device body 110 along a insertion member axis A1, and aconnecting arm 12 extending from the insertion member 11 and configuredfor connection to the aiming device 200. As illustrated in FIG. 2A, theinsertion member 11 defines a trailing end 5, a leading end 7 spacedapart from the trailing end 5 along a the axis A1, and a cannulation 111extending between the trailing and leading ends 5 and 7 along the axisA1. The trailing end 5 can define a leading end cannulation portion 115.The leading end 7 of the insertion member 11 can engage theintramedullary nail 300, as further detailed below and illustrated inFIGS. 9A-9C. The insertion member 11 defines an outer surface 112 andinner surface 113 that defines the cannulation 111. The insertion member11 also defines a cross-sectional dimension 150 that extends betweenopposing portions of the insertion member outer surface 112 and istransverse to the axis A1. The insertion member cross-sectionaldimension 150 is less than or about equal to the flexible sleevecannulation cross-sectional dimension 410. The insertion member 11 alsodefines a cannulation cross-sectional dimension 152 that extends betweenopposing portions of the insertion member inner surface 113 and istransverse to the axis A1. The insertion member 11 is thus configured toreceive in the cannulation 45 of the flexible sleeve 40. The insertiondevice body 110 also defines a secondary bore 107 that is offset fromthe axis A1. The secondary bore 107 is configured to receive therein atleast portion of the cap and hammer assembly (not shown) that can beused to advance the intramedullary nail 300 along the superior-inferiordirection S1. The insertion member 11 can include markings 117. Themarkings 117 on the insertion member 11 can be used to guide insertiondepth of the intramedullary nail 300 in the canal C. The markings 117are spaced a certain distance apart relative each other and also fromthe leading end 5 of the member 11 so that the intramedullary nailinsertion depth can be gauged with reference to the position of themarkings 17. The markings 117 can be radiographic and viewable via imageanalysis.

Turning to FIG. 9A, a connection device 15 can be used to connect theinsertion device 10 to the intramedullary nail 300. The connectiondevice 15, for instance an elongate rod 21, defines a proximal end 19,and a distal end 18 spaced apart from a proximal end 19 along aconnecting device axis A2. The distal end 18 can define an engagementtip 16 configured to engage the intramedullary nail 300. The rod 21 anddistal end 18 are sized to be slidably received by the insertion membercannulation 111. The rod 21 can also define a longitudinal bore 21 bextending along the axis A2 between the proximal 19 and distal ends 19and 18, respectively. When the connection device 15 is disposed in theinsertion member cannulation 111, the distal end 18 of the connectiondevice 15 protrudes from the leading end 7 of the insertion member 11 toengage the intramedullary nail bore 306. The intramedullary nail bore306 further defines internal threads 310 (FIG. 9B). The engagement tip16, which for instance is threaded, is configured to mate with theinternal threads 310 of the intramedullary nail bore 306 so as toconnect the intramedullary nail 300 and the insertion device 10. Theproximal end 19 of the connection device defines a socket 17, forinstance a hex socket. A drive mechanism 20 can be used to fix theconnection device 15 to the intramedullary nail 300. The drive mechanismcan define a distal tip 21 a configured to engage the socket 17 of theconnection device 15. To rotate the connection device 15, the surgeoncan insert the tip 21 a of a drive 20 into the socket 17 and then rotatethe drive 20 to threadably secure the device 20 to the intramedullarynail 300. It should be appreciated that the socket 17 can have anyconfiguration that can operably receive a distal end of a drivemechanism 20.

As shown in FIGS. 9A and 9B, the distal end 7 of the insertion member 11is configured to engage the intramedullary nail 300. The distal end 7 ofthe insertion member 11 defines a protruding tab 9. The proximal end 302of the intramedullary nail 300 defines at least one notch 308 (FIG. 9B).When the insertion member 11 is disposed on the intramedullary nail 300,the protruding tab 9 is received within the notch 8 so as to rotatablyfix the insertion device 10 relative to the intramedullary nail 300.During use, the surgeon can insert the tab 9 of the insertion device 10into the notch 308. Then, the surgeon can insert the connection device15 into the cannulation 111 of the insertion member 11. Next, theconnection device 15 is rotated (via the drive 20) relative to theinsertion member 11 such that the threaded tip 16 mates with theinternal threads 310 of the intramedullary nail bore 306 therebycoupling the intramedullary nail 300 to the insertion device 10.

Referring now to FIGS. 8A-9A, the connecting arm 12 is configured toattach to the aiming device 200. The connecting arm 12 defines a bodyportion 12 b and a connection member 12 a spaced apart from the bodyportion 12 b along the axis A1. The connecting arm 12 is offset relativeto the insertion member 11 such that the connection member 12 a isspaced apart from the distal end 7 of the insertion member 11 along adirection S3 that is transverse to the axis A1. The direction S3 can bethe same as the transverse direction S2 when the insertion device 10 isattached to the aiming device 200. The connection member 12 a definesone or more (at least two 13 a, 13 b) alignment holes 13, and aninternally threaded bore 14. The alignment holes 13 a, 13 b and threadedbore 14 are configured to receive portions of the aiming device 200.When the insertion device 10 is 1) positioned such that theintramedullary nail 300 is disposed in the medullary canal C, and 2) theinsertion device 10 is connected to the aiming device 200 by theconnecting arm 12 a, the aiming device 200 is aligned relative to theintramedullary nail 300 so that an anchor 8 is insertable into one ofthe intramedullary nail openings 305.

With reference to FIG. 10, the aiming device 200 may include an aimingmember 210 configured to guide at least one anchor toward the bone T andnail 300, and an attachment member 220 configured for connection to theinsertion device 10. The aiming member 210 defines an aiming body 230that is configured to support at least one guide sleeve 60 whereby theguide sleeve 60 is configured to guide the anchors 8 toward theintramedullary nail 300. The aiming member 210 can support, for instancefixedly support, a plurality of extension members 242, 244, and 246 thatextend perpendicularly with respect to the aiming body 230. Theextensions are configured to guide anchors into the bone T and nail 300.

In the illustrated embodiment, the aiming body 230 defines positionedbetween a first end 231 a and a second end 231 b spaced apart from thefirst end 231 a along a first transverse axis B1, and an apex portion238 positioned between the first and second ends. The aiming body 230can define a region R within which a portion of the patient's leg isreceived. The region R can be defined along the first transverse axis B1that is perpendicular to a second transverse axis B2 that extendsgenerally from the apex portion 238 into a patient's leg when the systemis positioned on the patient, and a third transverse axis B3 thatextends along the superior-inferior direction SR and is perpendicular tothe first and second transverse axes B1 and B2. The aiming body 230defines a superior side 232, an inferior side 234 spaced apart from thesuperior side 232 along the third axis B3. The aiming body furtherdefines an exterior wall 235 extending between the superior and inferiorsides 232, 234, and an interior wall 236 configured to face the leg andextending between the superior and inferior sides 232, 234. Theextension members 242, 244, and 246 extend from the aiming body 230along the axis B3. In the embodiment shown in FIG. 10, the extensions242, 244, and 246 protrude from the inferior surface 234 of the body230. In alternative embodiments, the extensions 242, 244, and 246 mayproject from or be attached to any side or portion of the aiming body230.

The aiming body 230 defines a plurality of channels 251 a-h configuredto at least partially receive and support either of a guide sleeve 60(FIG. 1), at least one anchor 8, a drilling assembly, or a drivemechanism 70. As illustrated in FIG. 10, channels 251 c and 251 f aredisposed in the aiming body 230, channels 251 a and 251 b are disposedin extension member 242, channels 251 d and 251 e are disposed inextension member 246, and channels 251 g and 251 h are disposed inextension member 244. Each of the plurality of channels 251 extendthrough the aiming body 230 along a transverse direction S2 and form apassage through which the guide sleeve 60 may be inserted through. Inaccordance with the illustrated embodiment, the inner surface (notnumbered) of each channel 251 is configured to slidably receive theguide sleeve 60 (FIG. 10). Specifically, each channel 251 is configuredsuch that when 1) the aiming device 200 is attached the insertion device10, and 2) the intramedullary nail 300 is positioned in the canal C, atleast one channel 251 is aligned with a direction that is transverse tothe intramedullary nail 300 and aligned with an opening 305 on theintramedullary nail 300. Further, each channel 251 may be configuredsuch that the guide sleeve 60 is manipulated within the channel 251 soas to align the distal end 61 of the guide sleeve 60 to the appropriatenail opening 305. One or more of the channels 251 can define elongateentry 257 and exit portions 256 when the channels are too close to eachother to permit non-biased positioning of the instrumentation, such asthe guide sleeve 60 and/or anchor 8. For instance, channel 251 b maydefine an elongate exit portion 256 facing the region R that allows forbiased positioning of a guide sleeve 60 and anchor 8. The channel 251 bis biased or tapered from the exit portion 257 toward the opposed entryportion (not shown) along the axis B1. The channel 251 b and exitportion 257 configuration allows controlled displacement of bonyfragments, provides contact and apposition under patient weight bearing.Further, channel 251 h can include an elongate entry portion 257configured to allow for biased positioning of instrumentation therein.The channel 251 h is biased or tapered from the entry portion 257 towardthe opposed exit portion (not shown) along the axis B1.

While the aiming body 230 and extensions 242, 244 and 246 are describedseparately above, in alternative embodiments, the aiming body 230 andone or more of the extensions 242, 244 and 246 may be integrally formed.Further, aiming body 240, for instance can be a curved frame configuredto support a guide sleeve. In still other embodiments, the curved frameis configured to support one or more extension members 242, 244 and 246,and the attachment member 220, wherein the extension members areconfigured to support the guide sleeve 60.

Continuing with FIG. 10, the attachment member 220 is configured toconnect the aiming device 200 to the insertion device 10. The attachmentmember 220 includes an attachment body 260, at least one (a pair 25 isshown) alignment pin 25, and a securing device 270, wherein thealignment pin 25 and the portion of the securing device extend from theattachment body 260 along the axis B2. The attachment body 260 defines abore (not numbered) that is sized to receive a portion of the securingdevice 270. The alignment pins 25 a and 25 b are configured to beinserted into the corresponding alignment holes 13 a and 13 b of theconnection member 12 a (FIG. 1). The securing device 270 defines a knobcoupled to an externally threaded shaft 28 with a free end 29 thatextends through the attachment body 260. The free end 29 of the threadedshaft 28 can extend into and through an attachment body bore (notnumbered) to mate with the corresponding threaded bore 14 on theconnection member 12 a. The aiming device 200 may be connected to theinsertion device 10 by inserting the threaded shaft 28 into threadedbore 14, while positioning the alignment pins 25 in the alignment holes13 of the connection member 12 a. The knob 270 may be rotated so thatthe threads of the shaft 28 mate with and engage the internal threads ofthe bore 14, thereby securing the attachment body 260 to the connectionmember 12 a. It should be appreciated that the position of nail 300,insertion device 10, and aiming device 200 can be manipulated as neededto facilitate alignment. For example, the surgeon can, via radiographicimage analysis confirm the position of the intramedullary nail 300 inthe tibial canal C.

While a knob 270 and threaded shaft 28 assembly is shown, other securingdevices may be used to fix the aiming device 200 to the insertion device10. In an alternative embodiment, the securing device may be a clampassembly configured to clamp the attachment body 260 to the connectionmember 12 a. In other alternative embodiments, the securing device 25can also be an interlock device that snaps-fits the attachment body 260and connection member 12 a together. Further, in other exemplaryembodiments, the attachment body 260 may be a cylindrical body having aninternally threaded bore, while the connection member 12 a hasexternally disposed threads configured to engage the threaded bore. Sucha configuration can couple the connection member 12 a to the attachmentbody 260, thereby connecting the insertion device 10 to the aimingdevice 200. In any of the alternative embodiments described above,provision may be made to ensure proper alignment of the insertion device10 relative to the aiming device 200, such as alignment pins, alignmenttangs or detents, alignment shoulders, and visual indicators (e.g. colorcoding) to indicate proper alignment.

Referring now to FIGS. 11A and 11B, the guide sleeve 60 is configured toguide at least an anchor toward the intramedullary nail 300 when theguide sleeve 60 is supported by the aiming device 200. The guide sleeve60 includes a distal end 62, a proximal end 64 spaced apart from thedistal end 62 along an axis G1, and a shaft 66 extending betweenopposing proximal 64 and distal ends 62 and along the axis G1. The shaft66 defines a guide sleeve cannulation 69 extending along the axis G1.The distal end 62 may be tapered. The proximal end 64 includes anengagement member 65 forming a ridge 68 extending from the shaft 66along a direction that is perpendicular to the axis G1. The ridge 68 isconfigured to abut an outer surface of the aiming member 210 when theguide sleeve 60 is supported by the channel 251. It should beappreciated that when 1) the intramedullary nail 300 is disposed inmedullary canal C, 2) the aiming device 200 is connected to theinsertion device 10, and 3) the guide sleeve 60 is supported by theaiming device 200, the anchor 8 is insertable through the guide sleeve60 into engagement with the bone T and into the corresponding opening305 in the intramedullary nail 300.

When the anchor is inserted through the guide sleeve 60, a drivemechanism can be used to secure the anchor 8 to the intramedullary nail300 and bone T. The drive mechanism 70 can include distal end spacedapart from the handle along a shaft portion. The distal end and shaftportions can be inserted through the guide sleeve cannulation 69 suchthat the drive distal end engages the anchor 8. The drive mechanism 70can be rotated so as to fix the anchor 8 into the opening 305 of theintramedullary nail 300 and the bone T. It should be appreciated thatother instrumentation may be inserted into the guide sleeve 60 asneeded. For instance, a trocar may be inserted through the guide sleeve60 to displace soft tissue proximate the cortex of the bone T. A portionof a bone drilling assembly may be inserted through the guide sleevecannulation 69 to drill an opening in the bone to provide access to theintramedullary nail 300. One or more protective sleeves can be insertedinto the guide sleeve cannulation 69.

The system can also include an extraction member (not shown) configuredto be least partially inserted in the cannulation 111 of the insertionmember 11 for operable connection the intramedullary nail 300 disposedin the medullary canal C. The extraction member may be connected to theintramedullary nail 300, locked in position and then pulled in asuperior direction A so as to remove the intramedullary nail 300 fromthe bone T.

Referring generally to FIGS. 1 and 12-17, the system 1 may be used toimplant a nail 300 in a medullary canal C of the bone T. Suprapatellarinsertion, as discussed above, is insertion of the intramedullary nail300 through a suprapatellar region SR of the leg as shown in FIG. 12A.To prepare for suprapatellar insertion and subsequent fixation of theintramedullary nail 300 to the bone T, the patient is placed in a supineposition on a radiolucent table. While placing the patient on theradiolucent table, the knee K of the injured leg may be positioned ontop of a knee roll 101 to ensure that knee K of the injured leg can bebent between an angle θ1 equal to about zero (0) degrees (fullextension), and a flexion angle θ2 that is between about 10 to 20degrees. Angles θ1, θ2 are defined between a femur axis F1 and a tibiaaxis TB1 as shown in FIG. 12A. During certain steps of the method asdisclosed herein, the injured leg is positioned at full extension todefine an angle θ1 of about 0 (zero) degrees, while in other steps theknee K is flexed. The leg can define a superior direction A and aninferior direction I. The directions A and I align with the direction S1discussed above.

Turning to FIG. 13, initially the fracture 950 can be reduced to restorethe fractured bone to its correct alignment. A distractor 900 depictedin FIG. 13 may be used to reduce the fracture, although any suitabledistractor may be used. The distractor 900 can include two spaced partsrods 925 and 935 positioned in the bone T on opposing sides of thefracture 950. The rods can be secured to the respective clamps 920 and930, and the spacing between the clamps 920 and 930, and thus rods 925and 935 are decreased or increased as needed.

The surgeon can determine and identify the appropriate nail 300 lengthafter reduction of the fracture 950. In an embodiment, the surgeon canuse a radiographic ruler (not shown) that can be placed along theinjured leg parallel to the bone T. The radiographic ruler is adjusteduntil its distal tip is at the level of the physical scar or the desirednail insertion depth. The surgeon then takes a radiographic image of thetibia and the ruler. The intramedullary nail length may be read directlyfrom the ruler image, selecting the measurement at or just below thelevel of the anterior edge of the tibial plateau.

Next, the knee K may be positioned at or near full extension (θ1˜zerodegrees) while the incisions 104 is made in suprapatellar region SR, asshown in FIG. 12B. The incision 104 can be made closer to or furtherfrom the patella P as needed, depending on anatomical and otherindications. A deep longitudinal incision (not shown) is made to splitthe quadriceps tendon in its midsubstance, just above its insertion intothe patella P.

Following the reduction and incision steps, the method proceedsgenerally by next preparing the medullary canal C for insertion of theintramedullary nail 300 therein, followed by insertion and fixation ofthe intramedullary nail 300 to the bone T. Accordingly, after theincision 104 is made, the preparation assembly 105 is assembled andinserted through the incision toward the proximal tibia. Specifically,flexible sleeve 40 in inserted into and retained by the retaining device50 as described above. The locking members 570 on the retaining member540, for instance can be depressed so as to permit the flexible sleeve40 to fit in the opening 560 and be received by the opening channel 580,as discussed above. The locking members 570 remained depressed so asretract the projections 574 within the wall 548, and then rigid sleeve30 is inserted into the flexible sleeve 40. When the locking members 570a and 570 b are released, the projections 574 a and 574 b engage therecesses 37 a and 37 b of the rigid sleeve engagement member 36 (FIG.7A). Next, the trocar 80 is then positioned within the rigid sleeve 30such that the tip 83 and a least a portion of the shaft 86 (not shown)protrudes from the leading ends 44 and 31 of the flexible sleeve 40 andthe rigid sleeve 30, respectively. As discussed above, the retainingdevice 50 thus holds the rigid sleeve 30, the flexible sleeve 40, andthe trocar 80 together. Next the blocking member 590 can be positioned ain blocking position Y (FIG. 2C) to block axial displacement along theaxis R1 of the rigid sleeve 30 and trocar 80.

Using the retaining device 50, the flexible sleeve, the rigid sleeve 30,and the trocar 80, is inserted through the incision 104 and is advancedalong an inferior direction I between the articular surface of thepatella P and the trochlea of the distal femur. Neither the rigid sleeve30 nor the flexible sleeve 40 penetrates the proximal portion of thebone T. however. During the insertion step the assembly 105, the patellaP is displaced anteriorly. With the knee K at extension, the assembly105 is advanced toward the tibia until the trocar 80 reaches theproximal surface of the tibia. As needed the surgeon can the repositionthe blocking member 590 as needed unblocking position. Then, the trocar80 is withdrawn in a superior direction A from the assembly 105 andpatient.

With reference to FIG. 14, next the wire guide 90 is inserted into therigid sleeve 30. The wire guide 90 is then advanced toward the anteriorsurface of the tibia T along the inferior direction I. As this point inthe procedure, the knee K is flexed between 10 and 20 degrees to providea radiographic location for a starting point and insertion of the wires106 a and 106 b. The wires can be then aligned with the desiredanatomical location. It should be appreciated that the wires 106 a, 106b can include a distal end 106 d, and a proximal end 106 p spaced apartfrom the distal end 160 d. The first wire 106 a is then inserted throughthe first bore 91 of the wire guide 90. The wire 106 a is then advancedto access the medullary canal C of the bone T. A radiographic image istaken to verify the position of the first wire 106 a. If the wire 106 ais positioned incorrectly, a second wire 106 b may be inserted throughthe second bore 92, along the groove 92 g toward the wire guide tip 91,while the first wire 106 a remains in place in the first bore 92. Thewire guide 90 may be then rotated within the rigid sleeve 30 to positionthe second wire 106 b at the desired location. The first wire 106 a canthen be removed from the wire guide 90 if the second wire 106 b ispositioned appropriately. When the wire 106 a or 106 b is in the desiredposition, the wire proximal end 106 p can be inserted into through thecannualated drill bit to guide the cannualated drill bit toward the boneT for forming the canal C. The cannualated reamer can be disposed alongthe wire 106 as needed. The system 1 can include multiple wire guidesconfigured for the appropriate surgical method, for instance the wireguides can have multiple cross-sectional dimensions and lengths asneeded for the particular leg anatomy.

With reference to FIG. 15, the retaining device 50 is subsequentlyanchored to maintain the position of the retaining device 50 during theprocedure. The fixing wire 107 is inserted through the transverse bore512 in the intermediate body 510 of the retaining device 50. The wire107 is advanced until its distal tip 107 d penetrates the patient'sfemur F. With the retaining device 50 fixed in position relative to theleg, a drilling assembly is used to prepare the canal C. The drillingassembly can include cannualated drill bit that can slide along the wire106. The drill bit can placed over the wire 106 and is then advancedthrough the rigid sleeve 30 until the drill bit reaches the bone T. Thedrill assembly is then used to open the medullary canal C. If necessary,a cannualated reamer may slide along the wire 106 and used to enlargethe medullary canal C. After opening the medullary canal C, the drillbit and the wire 106, wire guide 90 and rigid sleeve 30 are removed fromthe patient. With the medullary canal C prepared, the steps used toinsert and fix the intramedullary nail 300 to the bone T will now bedescribed.

The insertion device 10 may be coupled to the intramedullary nail 300 asdescribed above with respect to FIGS. 9A-9C. The rigid sleeve 30 isremoved from the retaining device 50 and the flexible sleeve 40. Withreference to FIG. 17, using the insertion device 10, the intramedullarynail 300 is inserted into the medullary canal C of the bone T throughthe flexible sleeve 40. If needed, a hammer assembly and cap candisposed in the bore 107 of body 110 and used to forcibly advance theintramedullary nail 300 into the medullary canal C. The appropriateposition of the intramedullary nail 300 can determined by usingradiographic imaging to determine the location of the markings 117 onthe leading end 7 of the insertion member 11, as discussed above.Further, the position of the distal end 304 in the medullary canal C maybe determined using radiographic imaging or other means.

With reference to FIG. 1, when the intramedullary nail 300 is positionedappropriately in the medullary canal C, the aiming device 200 isconnected to the insertion device 10. The alignment pins 25 arepositioned inside the bores 13 of the connection member 12 a, while thesecuring device 27 secures the attachment body 260 to the connectionmember 12 a, thereby aligning the at least one channel 251 with at leastone opening 305 of the intramedullary nail 300. Preferably, one or morechannels 251 are aligned with one or more corresponding openings 305. Aguide sleeve 60 may then be inserted through the channel 251 of theaiming device 200 as shown in FIG. 1. Next, a portion of the bone drillassembly is positioned within the cannulation 69 of guide sleeve 60. Thedrilling assembly forms an opening in the bone T at a location proximatethe opening 305 aligned with the selected channel 251. The drillassembly is then removed from the guide sleeve 60. Next, an anchor 8 ispositioned on the distal end of the drive mechanism 70, and the anchor 8and drive mechanism 70 are inserted into cannulation 69 of the guidesleeve 60. The drive mechanism 70 is use to rotate the anchor 8 so thatanchor 8 engages the opening 305 of the intramedullary nail 300 therebyfixing the intramedullary nail 300 in the bone T. Additional anchors 8can be positioned and fixed to the intramedullary nail 300 as needed.

It should be noted that the illustrations and discussions of theembodiments shown in the figures are for exemplary purposes only, andshould not be construed limiting the disclosure. One skilled in the artwill appreciate that the present disclosure contemplates variousembodiments. It should be further appreciated that the features andstructures described and illustrated in accordance one embodiment canapply to all embodiments as described herein, unless otherwiseindicated. Additionally, it should be understood that the conceptsdescribed above with the above-described embodiments may be employedalone or in combination with any of the other embodiments describedabove.

What is claimed:
 1. A method for inserting a securing a nail into amedullary canal of a bone, the bone defining a proximal end, and adistal end spaced apart from the proximal end along a first direction,the method comprising: supporting a flexible sleeve with a retainingmember, wherein the flexible sleeve defines a leading end, a trailingend spaced apart from the leading end along a first axis, and a firstcannulation extending between the leading and trailing ends along thefirst axis; coupling an insertion device to the intramedullary nail; andadvancing the insertion device and nail into the first cannulation ofthe flexible sleeve so that the intramedullary nail is advanced into themedullary canal along the first direction.
 2. The method of claim 1,further comprising the step of connecting an aiming device to theinsertion device, wherein the aiming device is configured to support aguide sleeve.
 3. The method of claim 2, wherein the aiming devicefurther defines at least one channel, and the method includes the stepof inserting the guide sleeve in the at least one channel toward thebone along a second direction that is transverse to the first direction.4. The method of claim 3, further comprising the step of inserting atleast one anchor through the guide sleeve into engagement with the boneand the intramedullary nail positioned in the medullary canal. 5-11.(canceled)